To manage and coordinate incoming grievances and appeals and provide administrative support for the Grievance Unit. Assesses and completes appropriate documentation for tracking and trending date, which may include conducting all pertinent research on a level one grievance in accordance with all established regulatory guidelines. Reviews delegated grievance logs and processes requests for grievance data and reporting.

• Answers unit’s incoming calls and responds to PHC member’s inquiries accordingly.
• Enters grievances and appeals in the Everest system. Checks Centers of Medicare & Medicaid Services (CMS) website for incoming CMS grievances and inducts grievance as appropriate.
• Responsible for maintaining grievance information and supporting documentation in accordance with regulatory bodies for all lines of business.
• Prepares and maintains monthly, quarterly, semi-annual, and annual reports as assigned.
• Assigns case work to Grievance Coordinators using a rotation schedule.
• Schedules and creates meeting material for meetings and coordinators schedules. Prepares and edits meeting minutes and meeting material.
• Reviews PCP Transfer Report/End of Business Day Report and reports issues to the Grievance Supervisor.
• Maintains knowledge of the current regulatory standards, internal policies and procedures, member benefits, and member materials (such as handbooks).
• Identifies: potential HIPAA privacy issues to the Privacy Officer; potential quality issues to the Quality Improvement Department; potential issues involving Fraud, Waste, and Abuse to the Compliance Department.
• Prints, faxes, mails, photocopies, and scans provider correspondence.
• Processes incoming invoices of payment and obtains authorization on invoices and requisitions.
• Identifies errors and deficiencies to management in regards to quality and compliance.
• Assists in the creation and distribution of various project documents.
• Participates in audits and trainings.
• Other duties as assigned.

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

HIRING RANGE:

$ 24.12 - $ 29.55

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.